Bria of Westmont

In the surveyor’s words

From the most serious findings on record at Bria of Westmont, in the surveyor’s own words.

• Immediate jeopardy, patternF690Aug 4, 2022

  Based on observation, interview, and record review the facility failed to follow the facility's policy for monitoring urine output for residents with indwelling urinary catheters. The facility also failed to ensure residents with indwelling urinary catheters received catheter care. This failure resulted in R1 experiencing marked distension of the urinary bladder with urine retention of 900 ml (milliliters) of purulent, bloody urine and being admitted to the local hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy began on July 9, 2022, when the facility failed to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy was identified on August 2, 2022. […]

• Immediate jeopardy, patternF692Aug 4, 2022

  Based on observation, interview, and record review, the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to follow the facility's policy for administering and documenting the total amount of tube feeding received by the residents. This failure resulted in R1 sustaining a significant weight loss of 6.38 percent in one month, developing a facility-acquired pressure ulcer, and being hospitalized for [CONDITION(S)] and dehydration. The Immediate Jeopardy began on July 5, 2022, when R1 was seen by V6 (NP-Nurse Practitioner) for abnormal lab values and appeared dry on examination after the facility failed to ensure R1 received enteral tube feedings and free water flushes as ordered by the physician. […]

• Actual harm, isolatedF692Aug 18, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents were receiving tube feeding as ordered.This failure resulted in R1 and R8 experiencing significant weight loss.This applies to 2 of 3 residents (R1 and R8) reviewed for tube feeding in the sample of 10.The findings include:1. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including epilepsy, chronic obstructive pulmonary disease, severe protein-calorie malnutrition, dysphagia, bipolar disorder, dementia, and contractures of the left and right ankle, left wrist and left hand.R1's MDS (Minimum Data Set) dated July 9, 2026, showed R1 had severely impaired cognitive skills for daily decision making and was dependent on facility staff for… […]

• Actual harm, isolatedF604Aug 1, 2026

  Based on interview and record review, the facility failed to prevent a resident with increased confusion and identified as a high fall risk from being physically restrained. This failure resulted in the resident being barricaded in her bed surrounded by dressers.This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 5.The findings include:R1's face sheet showed multiple diagnoses that included unspecified fall, subsequent encounter, other abnormalities of gait and mobility, weakness, tremor, cognitive communication deficit, unspecified psychosis, bipolar disorder, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, recurrent severe without psychotic features, abnormal… […]

• Actual harm, isolatedF684Jan 28, 2026

  Based on interview and record review the facility failed to ensure a physician was notified with Xray results for a resident with a confirmed fracture and failed to ensure prompt emergency care was provided for a resident with a confirmed fracture. This applies to 1 of 3 residents (R3) reviewed for change of condition in the sample of 13. This failure resulted in R3 experiencing a delay in emergency and surgical care after sustaining an acute comminuted and displaced distal femur fracture with large lipohemarthrosis (collection of fat and blood) and a subacute fracture of the proximal fibular diaphysis. […]